Ask About Services

WELCOME! We're glad you stopped by. This is not our intake form. We only need enough information to determine which FPS provider is most able to serve you based on expertise, insurance panels, and availability. Be aware that we do not accept crisis intakes through this form. If you or your child is in crisis or at risk of self harm, please call 911 or go to your nearest psychiatric crisis center.

We respond quickly. Our care coordination staff will review this material and get back to you by secure email within 1-2 business days at most. If by the third business day you have not heard back, something has gone wrong. First check your SPAM folder then call 785-371-1414 and let them know that you are have submitted an Ask About Services Form and have not heard from us.

Client's First Name

Client's Last Name

Age of Client

Date of Birth of Client

Gender of Client

Client Address: Street

City

State

Zip Code

Primary Care Physician

Daytime Phone Number

Other Phone Number

Best Email Address (Enter correctly. This is how we will contact you)

Current School Attended (if a student)

SERVICE MODALITY

In Office Telehealth

(NOTE: Telehealth is only offered for qualified clients over 18-years-of-age living in an underserved area of Kansas sixty miles beyond Lawrence)

PREFERRED APPOINTMENT TIME (After 3pm times are limited)

Daytime (9am to 2pm) Afternoon (2pm to 5pm) Evening (5pm to 8pm) Saturday (limited availability) No preference (selecting this option gives you the best chance of getting on our schedule)

REFERRED BY:

Please take a photo of the front of your insurance card and upload it by clicking the "choose file" button below. Failure to do so will make it more difficult for us to assess your costs and may slow the process.

Choose File

Add file

Please upload a file

Does the client have secondary Insurance?

No, client does not have secondary insurance Yes, client has the following secondary insurance

Secondary Insurance Company

Who is responsible for paying the client's bill?

Please Note: For children of divorced parents, the party who presents the child must sign as responsible for any charges not covered by insurance, regardless of divorce or custody decrees.

DETAILED SYNOPSIS: It is essential that you provide a detailed summary of what brings you or your child to see us. Please don't leave this blank. We need this information to assign your case. This information is securely received and stored.

DO NOT leave this box blank. We need this information to assess scope of practice and assign your case. The more detail you provide the better we can assess our ability to serve you.

Your information will be encrypted.

Ask About Services

Family Psychological Services